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NHS trust fined following falls deaths

Date:
28 November 2017

Shrewsbury and Telford Hospital NHS Trust has today been fined following a series of Health and Safety Executive (HSE) investigations into the deaths of five elderly patients.

Stafford Crown Court heard that the patients, aged between 72 and 92, sustained fatal injuries as result of falling while being cared for in hospitals run by the Trust. Four died as result of falling at the Princess Royal Hospital, Telford. The fifth succumbed to injuries at the Royal Shrewsbury Hospital. The deaths took place between June 2011 and November 2012.

The HSE investigations found that fall prevention measures, including close supervision of those in a confused mental state, were not properly applied. This was made worse by poor consideration and communication surrounding measures to protect against falls arising from each patient’s particular frailties.

Shrewsbury and Telford Hospital NHS Trust of Princess Royal Hospital, Apley Castle, Telford pleaded guilty to breaching Section 3(1) of the Health and Safety at Work Act 1974. Today it was fined £333,333 and ordered to repay £130,000 in costs.

In a statement, Lucy Anderson Edwards, a great niece of Edna Evans, one the patients who died, said on behalf of the family:

“Edna was a wonderful sister, Aunt and finally a Great Aunt to myself, sitting proudly as the eldest at the head of the family. It’s been a difficult five years without such a special lady who I regarded as another grandparent having lost her own child many years ago, and even more difficult with all the speculation surrounding her death.

“I am just thankful that after today’s events myself and the rest of her remaining family can finally have some closure and move on from the somewhat horrifying past events and undignified circumstances in which Edna passed away.

“Nothing will ever rectify, and nothing will ever justify the tragic events that led to Auntie Edna’s death, but today I am grateful for the Shrewsbury and Telford Trust’s open admittance to fault and I can only hope that bringing my Aunt’s case to light will go a long way in preventing such catastrophic future errors.

“My thoughts are with fellow families and friends of other loved ones who also fell victim to a failure of care from the Shrewsbury and Telford Hospitals Trust. I hope they too can find some comfort in the final closure of these investigations.

“Finally as a family we’d like to thank the Health and Safety Executive for pursuing this investigation, as well as its impeccable support and professionalism throughout the whole lengthy case in aim of achieving the best justice possible.”

Vince Joyce, Health and Safety Executive Principal Inspector for Shropshire said:

“First of all, our thoughts remain with each of the five bereaved families, as they have throughout our investigations. Our thorough inquiries found that these elderly patients, already vulnerable, were exposed to an acute risk of serious injury from falling.

“It was the duty Shrewsbury and Telford Hospital NHS Trust to take reasonable precautions to prevent vulnerable patients from falling. Although policies and procedures were in place for this to happen, they were not consistently applied at the point of care. In different ways, these patients were left exposed to the risk of falling which resulted in their deaths. It is right for the Trust to have been held to account for those failings in the Court today.”

Background

Mohan Singh, 74, was admitted to the Princess Royal Hospital on 15 June 2011. It was recommended that he had Enhanced Patient Supervision i.e. bed watch. At about 4am on 17 June 2011, Mohan fell to the floor and sustained a bilateral subdural haematoma. He died on 21 July 2011.

Eileen Thomson, 81, was admitted to the Princess Royal Hospital on 3 May 2012. During her stay in hospital she had three falls. Following the third fall a CT scan revealed she had a subdural bleed. She died on 16 May 2012.

Edna Evans, 92, was admitted to the Princess Royal Hospital on 2 October 2012. She suffered a fall on 3 October. An x-ray confirmed a fracture to her shoulder. She was discharged on 24 October. Edna died at home on 30 October. Her post mortem found that the injury she sustained from her fall contributed to her death.

Ada Clarke, 91, was admitted to the Princess Royal Hospital on 24 October 2012. On 29 October, another patient saw she was trying to get out of her bed. Shortly afterwards Ada was found at the side of her bed having fallen. She died later that evening.

Gerald Morris, 72, was admitted to the Accident and Emergency Department of the Royal Shrewsbury Hospital on 5 October 2012, having suffered a fall at home. On 11 October Gerald fell while walking to bathroom and was diagnosed four days later with a fractured left hip. He underwent two operations to repair his hip, but died on 18 November 2012.

Notes to Editors

  1. The Health and Safety Executive (HSE) is Britain’s national regulator for workplace health and safety. We seek to prevent work-related death, injury and ill health through regulatory actions that range from influencing behaviours across whole industry sectors through to targeted interventions on individual businesses. These activities are supported by globally recognised scientific expertise. www.hse.gov.uk
  2. Until the 1 April 2015, decisions whether or not to investigate patient safety matters in England were made in line with our HSWA Section 3 policy: http://www.hse.gov.uk/enforce/hswact/priorities.htm After this date, the Care Quality Commission (CQC) became the lead inspection and enforcement body under the Health and Social Care Act 2008 for safety and quality of treatment and care matters involving patients and service users in receipt of a health or adult social care service from a provider registered with CQC.
  3. Since 1 April 2015, this HSE investigation was conducted as a historic inquiry, as the HSE was the appropriate regulator at the time these offences were committed.
  4. Further information about how the HSE decides on whether to investigate can be found at http://www.hse.gov.uk/enforce/incidselcrits.pdf
  5. Section 3(1) of the Health and Safety at Work etc. Act 1974 states: “It shall be the duty of every employer to conduct his undertaking in such a way as to ensure, so far as is reasonably practicable, that persons not in his employment who may be affected thereby are not thereby exposed to risks to their health or safety.” Further information about the legislation applied in this case can be found at www.legislation.gov.uk/.

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